ASSOCIATION OF DIRECTORS OF PUBLIC HEALTH (ADPH) – WRITTEN EVIDENCE (PSR0069)
House of Lords Public Services Committee Inquiry – Lessons from Coronavirus
On 17th June, the President of the Association of Directors Public Health (ADPH) Dr Jeanelle de Gruchy was invited to give oral evidence to the House of Lords Public Services Committee. This written submission is intended to complement and reinforce the messages ADPH presented during the oral evidence session.
The ADPH has taken a clear view about our approach to COVID-19 and engaging with the Government: to be as constructive as possible and as challenging as necessary. There are immense challenges and strong collaboration is a key part of saving lives. Our early thoughts about the response to COVID-19 are very much made in the spirit of improving what we can do now and putting in place what will be needed in the weeks and months ahead. Those must be the priorities for all.
In time we will need to consider what has worked well and what has not – and strengthen the system for the future. We must ensure that we are better prepared for future pandemics, this includes reflecting on current structures, roles and responsibilities, as well as ensuring that each part of the system is adequately funded and resourced. Any review of the Public Health system’s response and readiness for future pandemics needs to be scoped and conducted as a whole system with both national and local partners. The need for neutrality in designing our future Public Health system is vital.
There are also broader questions to consider about the government’s approach to health and prevention. The health inequalities that exist in the UK have once again been starkly exposed and amplified. The government must start by setting out a comprehensive response to the Prevention Green Paper consultation. As a society we still tend to think that a healthy population is created by the NHS – this is not the case.
However, these are much longer-term conversations; we need to recognise that we are still in the early stages of this pandemic. There is more immediate learning that we must reflect on now, as we move into the next phase of the pandemic.
In recent weeks, there has been increasing recognition about the value of local public health leadership as a vital component of an effective response to COVID-19. Directors of Public Health (DsPH) are continuing to build closer working relationships with the Chief Medical Officer (CMO) and Deputy Chief Medical Officer (DCMO), Public Health England (PHE) and other local partners. The whole public health system has been strengthened over the course of the pandemic and has risen to the sheer scale of this challenge.
- What failures has the outbreak exposed in central and local government cooperation on public service delivery, and how could public service reform address such issues?
- DsPH have a clear role to play and are working relentlessly to ensure that the local response is as effective as possible across the UK. In the early stages of the pandemic, DsPH produced local guidance and information for other council departments, elected members and the wider community, as well adapted local services to ensure resources were focused on the task at hand e.g. sexual health and drug treatment services have enhanced their online offer. DsPH have been the ‘go-to’ source of knowledge and information for numerous agencies when it comes to planning and providing local analysis, and have been working closely with the local media and community groups to promote clear public health messages and advice. Most recently, DsPH have developed Local Outbreak Plans – working with colleagues in local government, the NHS, PHE and other partners - to deliver a coordinated place-based approach.
- Despite leading so much of this work locally, DsPH have been left off time and time again from key communications or guidance developed by NHS England and Government departments.
- We recognise that in the early days of the pandemic, decisions and announcements needed to be made at pace. However, the lack of coordination and foresight has presented real challenges for DsPH. DsPH have often been put on the back foot locally, leaving them with little time to plan and prepare ahead of policy announcements or new guidance landing. Particularly at the start of the pandemic, announcements were made – for example at the daily briefing – and DsPH were left to interpret and explain them as the structures and protocols for implementing them were not always in place.
- For example, guidance on Personal Protective Equipment (PPE) has often been unclear and not backed by sufficient supplies, particularly in care settings. Government guidance (which came into effect on March 23) encouraged care homes to accept discharged patients if they were asymptomatic, without any testing or sufficient access to PPE in place. This has severely impacted on the situation in care homes. In recent weeks, there has been greater involvement by DsPH in overseeing testing and outbreak management in care homes. This has been hugely valuable – however, this engagement should have come earlier. The best decision making can only happen if the right people are in the room – that must include those working on the ground in local government.
- NHS Providers has recently called on the government to commit to a set of protocols for all future announcements affecting the operations of the NHS. This equally applies to local government, with DsPH calling for the following:
- DsPH should be properly consulted on the content of major changes and on the details of announcements that affect them.
- DsPH should get as much notice as possible of any announcement and as a bare minimum, should be provided with a copy of the announcement at the same time it is made public.
- Detailed guidance should be made available in a sufficiently timely way to enable effective implementation within the accounted implementation deadline.
1.2. Disconnect between national and local government
- Whilst some aspects of the Government’s response to COVID-19 have been commendable, the centralised nature of some elements has, in some cases, significantly impeded effective collaboration and communication with local authorities.
- DsPH, and local government as a whole, were not engaged and involved early enough in national plans for COVID-19 generally and contact tracing specifically. This has, however, improved considerably in recent weeks.
- There has been a significant disconnect between how policy is formed nationally and how it is implemented on the ground. The top down approach by government has meant that DsPH – particularly in the early months of the pandemic – were side lined in terms of the national decision making and centrally run programmes (i.e. PPE and the testing regime). There has been an assumption that one-size fits all – and that has proved costly.
- With testing for example, ambitious targets were set without a clearly communicated rationale for the testing programme overall. The focus should have been on setting out this rationale, with the support of local partners, to better understand local needs and how it can be effectively implemented on the ground.
- DsPH are the local experts. DsPH and their teams have extensive knowledge of their communities and the wider health and social care system. They have a critical contribution to make in developing approaches that work on the ground and in ensuring they reflect the diversity of communities and the range of needs that exist (from language to inequalities). DsPH have played a key role in stitching together the different elements of the pandemic response - whether it be on PPE, volunteering, or testing - to ensure that the system is joined up.
- The confusion around local lockdowns provides an example of where there has been a considerable disconnect and a lack of coordination nationally. There has been much focus on the idea of ‘local lockdowns’, but the Government has not yet defined what the term means, outlined how, where and when they could be applied, or considered the question of whether they would be either desirable or practical.
- Looking forward, it is clear that no single organisation or agency, whether national or local, can design and oversee an operation like Test and Trace alone. The success of this programme – and the UK’s overall response to COVID - depends on a truly integrated approach between national and local government and a range of other partners across the system.
- Greater local involvement is needed in formulating national policy. This means bringing in bodies such as the Association of Directors of Public Health, the Local Government Association and Association of Directors of Adult Social Services to collaborate and inform policy.
1.3. Poor recognition of the role of DsPH and the local public health system
- The local public health system has been undervalued. The response to the pandemic and in particular, the limited engagement with DsPH in the early stages, reflects the historic lack of understanding of the importance of public health and the role of DsPH in creating healthy populations and places. As a society we tend still to think that a healthy population is created by the NHS – it is not.
- DsPH are trained in containing infectious diseases, both understanding and interpreting data, recognising risk factors, understanding the evidence base and what motivates behaviour change, and helping develop policy interventions. Contact tracing is also a tried and tested public health intervention.
- DsPH - and their teams - have extensive experience and knowledge of contact tracing, their local communities and the wider health and social care system. Within local government, there are plenty of people with the skills – from environment health officers to public health specialist and sexual health staff – to support the contact tracing efforts in response to the coronavirus. However, the involvement of local councils and DsPH in the Test and Trace service was, up until recently, fairly limited.
- In recent weeks, there has been increasing recognition about the value of local leadership as a vital component of an effective response to COVID-19. DsPH have been brought in to provide a local perspective and inform the design of the system. They are working at pace to develop Local Outbreak Plans, which are intended to build on existing plans to manage outbreaks in specific settings, ensure the challenges of COVID-19 are understood, consider the impact on local communities and ensure the wider system capacity supports DsPH.
- Recent developments, including the secondment of Tom Riordan to lead on the Trace element of the programme, has significantly boosted local government’s role and voice nationally. However, the overall programme continues to feel ‘top down’ with DsPH having to knit together how this all will work on the ground. Similarly, with the Joint Biosecurity Centre (JBC), although DsPH and other local partners are increasingly being consulted, it is still very much seen from a national lens.
- Adult social care was the first area in which the role of the DPH was strongly recognised. Largely championed by PHE, DsPH have been brought in and given more ability to influence. Alongside their Director of Adult Social Care (DASS) colleagues, DsPH are now playing more of a leading role in outbreak management, and this includes enabling DsPH to use to their local expertise to prioritise the allocation of testing in care homes.
- ADPH has welcomed increased engagement with colleagues from the Department of Health and Social Care (DHSC), in particular, the Minister of State for Care. This has allowed DsPH to provide the necessary input into national policy, engage in joint problem solving and feedback key issues and how things are working on the ground.
1.4. Lack of investment in public health and prevention
- Recent polling data from the Health Foundation shows that there has been an increase in the public’s perception of the responsibility the government has to ensuring people stay healthy. In 2018, 61% of those polled said they felt that the government had a great/fair amount of responsibility. In May 2020, this increased to 86%.
- The Government must prioritise health inequalities, which have once again been starkly exposed and amplified. They should do this by setting out a comprehensive response to the Prevention Green Paper consultation and reflect on recent work such as the Marmot 10-Year Review. A summary of ADPH’s response to the Prevention Green Paper can be found here.
- PHE’s recent reports ‘Review of disparities in risks and outcomes’ and ‘Beyond the Data: Understanding the Impact of COVID-19 on Black Asian and Ethnic Minority (BAME) communities’ clearly highlight the disparities that exist, and that COVID-19 does not affect all population groups equally. It is important to see this national leadership. The recommendations set out by PHE must now be reflected on and actioned.
- DsPH are continuing to take on this leadership role to address inequalities at a local level. Locally, Councils have played a significant role in the first phase of the pandemic by engaging local communities, developing culturally appropriate outreach and programmes, working with local faith institutions and leaders, supporting and shielding vulnerable persons, and providing food, financial and social support to those who had been severely affected and isolated.
- National government needs to recognise and support the collaborative work local councils are doing to address inequalities. For example, in early May, the public health divisions in Birmingham and Lewisham public health announced their collaboration to address ethnic inequalities, through an increased understanding, appreciation and engagement with BAME groups.
- There must be a recognition across government of the value of taking a whole system, place-based approach to tackling inequality. This includes wide-ranging action to improve the social determinants of health (i.e. education, housing, air quality) as well as acting on the health inequalities caused by the commercial/behavioural determinants of health such as smoking, alcohol use and obesity.
- Wellbeing should be built into the fabric of Government decision making – both when it comes to policy development and funding allocation. Too often health is a second order priority, when it should be the foundation without which individual flourishing and economic prosperity cannot be realised.
- Did funding issues limit the ability of local services to respond to the crisis and, if so, which services proved the least resilient?
- ADPH welcomed the government’s announcements of two allocations of £1.6bn of additional funding for local government including to help manage public health pressures. However, the Local Government Association (LGA) estimates that the total cost pressures of responding to COVID-19 will be three or four times more than the £3.2bn allocated to local government so far.
- The extra £300m announced for Local Outbreak Plans was also welcomed. However, this does not reflect the full pressures faced by public health and other parts of local government. Also, if this is a one-off sum, then a medium-term response will be challenging in terms of resource and capacity. Without sustainable funding, we cannot invest in the skills and people we need.
- The reality is that a decade of cuts to local government and public health budgets have left us in a less resilient place than would have otherwise been the case. Prior to COVID-19, local authority public health was operating under significant financial pressures. Analysis by the Health Foundation shows that the public health grant is now £850m lower in real terms than initial allocations in 2015/16.
- Public health functions are continuing to experience a range of pressures in relation to early years support, drug and alcohol treatment, sexual and reproductive health services and staffing costs. Councils have worked incredibly hard to maintain services and look for alternative ways of delivering and supporting their communities over the course of the pandemic. This has been delivered despite the increased deployment of staff, people going off sick or having to isolate.
- The government has pledged to provide whatever funding the NHS needs – it is crucial that this approach is also applied to local government.
- Certainty on the extent to which excess spending by councils on coronavirus measures will be covered by government, and clarity on funding levels for 2021/22 and beyond will allow local government to optimise recovery strategies. There are, and will continue to be, additional responsibilities such as sustaining resilience measures, contact tracing, PPE and increasing costs in areas such as social care and homelessness. These will require funding.
- The DHSC and Ministry of Housing, Communities and Local Government (MHCLG) should work with ADPH to understand what level of funding public health teams need to cope with the immediate and medium response to COVID-19 and service pressures, as well as work proactively on a long-term settlement to support recovery through the Autumn Spending Review.
- One key lesson we need to learn from this pandemic is that maintaining a well-resourced public health system, including health protection and Public Health analysis functions, is not a “nice-to-have” but a “must-have”.
- How effectively have different local and national services been able to share data during the outbreak, and what obstacles to data-sharing now need to be addressed?
- National bodies have been slow to provide local authorities with data – this has caused significant problems. During the containment phase, for example, DsPH were struggling to get information on the positive cases in their area. This often meant DsPH were learning about cases via the media and left on the backfoot when responding to requests for advice from settings such as schools.
- Data is needed for both surveillance and outbreak management, which involves ensuring that appropriate advice and support is provided to cases and contacts where needed.
- With care homes for example, DsPH are unable to plan their local responses without detailed individual-level data for each person tested and crucially, whether it is a positive, negative or void result. For staff who are tested, DsPH need to know their postcode details so that they can identify where there may be a risk of community transmission and local outbreaks outside of the care homes.
- DsPH are continuing to report several issues around data which fall into five categories; gaps (data not being shared with DsPH and councils), consistency (with regional variations in what is being provided and when), quality and accuracy, timelessness and usability.
- Currently most of the data available to local authorities and combined authorities is still only based on Pillar 1 testing, i.e. those tests carried out in PHE or NHS labs. Based on the UK figures, it is estimated that about a third of positive tests relate to the Pillar 2 testing; without the Pillar 2 testing data it is therefore not possible to get a full picture of infection rates.
- With limited and unreliable access to data, DsPH have often had to rely on relationships with local organisations and local NHS colleagues to get hold of information. Or, in the case of care home testing, DsPH have had to establish lines of communications to obtain results from them rather than receiving them directly. This is resource intensive and time consuming.
- In general, data and intelligence sharing from PHE to local authorities has worked better when existing systems and processes have been used. Where new arrangements have been established - for example, with testing and contact tracing – data flows have been more problematic.
- DsPH are working at pace to develop Local Outbreak Plans by the end of June. Timely data flows from all parts of the NHS Test and Trace Service will be a critical tool in managing and containing COVID-19 at a local level. ADPH is continuing to work constructively with national agencies to ensure DsPH and their teams have access to the data they need to carry out their responsibilities.
- Has coronavirus exposed weaknesses in the relationship between NHS England and councils, and Public Health England and local directors of public health? If so, how can these weaknesses be addressed?
The effective delivery of local health protection services requires close partnership working between PHE, the NHS and local government, amongst others. The whole public health system has been strengthened over the course of the pandemic and is rising to the sheer scale of this challenge.
While there are some more immediate issues that can be addressed, a longer-term conversation is needed to reflect on the lessons learned and explore how these relationships can be strengthened going forward.
4.1. Relationship with NHSE
- Unfortunately, this has been managed as an NHS crisis rather than a public health crisis. It has only recently been considered as the latter.
- Like national government, the NHS often takes a top-down approach. This has resulted in DsPH having to find work arounds. It is vital that we work as a whole system and ensure that all partners are engaged and informed.
- At the start of the pandemic, the NHS, quite rightly, started compiling guidance on community health services prioritisation e.g. what services should be paused or reduced in the short term. Some of these services were either local authority commissioned or impact upon local authority commissioned services, however ADPH and DsPH were not initially consulted. Although this has now been rectified and improved, this is a clear example of where a conversation should have happened at an earlier point.
- Undoubtedly, the pandemic will raise questions as to whether local government is the right place for public health to sit. The answer to this is yes – we are in exactly the right place.
- DsPH understand the diversity and needs of their local communities. It is this local knowledge and expertise, alongside the understanding of “how policy is playing out”, that is so crucial to ensuring that we have a good health protection response locally.
- Being within local councils has also allowed for a joined-up approach, as public health teams are able to work more collaboratively with partners in the local system, including schools, businesses, social care, the police, transport sector, and the community and voluntary sector. This has proved vital during the initial response and will be crucial as DsPH continue to develop and implement their Local Outbreak Plans.
- The coronavirus has laid bare the inequalities that exist in our society. A whole system, place-based approach is needed to tackle these inequalities. This includes wide-ranging action to improve the social determinants of health, as well as action on the health inequalities caused by the commercial/behavioural determinants of health such as smoking, alcohol use and obesity. Local authority public health teams are well placed to provide the necessary system leadership. The NHS, on the other hand, is not fundamentally set up to focus resources on prevention. It is estimated that healthcare contributes to only 10% to 20% of all our health.
- Primacy of place should be the key principle that underpins joint working and integration initiatives across local government and the NHS.
- When public health teams moved into local authorities in 2013, the ADPH warned that the close relationship that existed between public health and the NHS must not be lost in the transition. Unfortunately, some of that closeness has been lost. Too often, NHSE links to PHE and assumes that is enough to have a whole system approach. Going forward, it is essential that there are clear local and national links between NHS and local PH teams.
4.2. Relationships with PHE
- At a regional and local level, DsPH have worked closely with PHE Centres prior to, and during the course of the pandemic. While there is variation across the regions, PHE and ADPH are continuing to explore opportunities to strengthen these relationships. In our last membership survey (2019), over 75% of DsPH responded that they have a positive relationship with their PHE Centre.
- Wherever there has been an existing, strong relationship between local DsPH and the PHE Centre Directors, this has made working together during the pandemic a smoother process and, if anything, has strengthened the natural partnerships.
- Last year, PHE appointed Regional Directors of Public Health for the seven new NHS regional management teams. These new regional roles provided a valuable opportunity to link in more with the NHS and influence work around health inequalities. Local DsPH welcomed these appointments but cautioned that strong links to local public health must maintained.
- ADPH and DsPH are continuing to work closely with PHE and the regional Centres to foster stronger and more productive working relationships, a greater understanding of the local government context and avoid duplication of work. At a national level, COVID-19 has strengthened the dialogue between PHE and ADPH. This is positive and welcome.
4.3. Strengthening our Health Protection system
ADPH and PHE recently published a guide on What Good Looks like for High Quality Local Health Protection Systems. However, a longer-term conversation is needed to reflect on the lessons learned during this pandemic and explore how we can strengthen the public health system as a whole. This includes the following:
- Having clearer lines of accountability for working across health protection practice - particularly in relation to emergency planning and response - with strong leadership roles for Local Health Resilience Partnership and DsPH.
- Ensuring there are strong system-level governance arrangements, particularly in relation to emerging systems such as the Test and Trace Service.
- Promoting a collaborative culture of openness, transparency and shared objectives at a system level, for the protection of the public’s health. As well as ensuring effective sharing and linking of data, to inform health protection action.
- Agreeing knowledge management mechanisms including the routine sharing of best practice approaches, curation of information, and learning from colleagues in other organisations
- Ensuring proactive efforts are made to build links between health protection and other areas of work in local government, including environmental health and education.
- Strengthening links between formal health protection services and public and voluntary sector organisations working with high risk or vulnerable groups, e.g. homelessness services and drug and alcohol services.
Any review of the Public Health system’s response and readiness for future pandemics needs to be scoped and conducted as a whole system with both national and local partners. The need for neutrality in designing our future Public Health system is vital.
Association of Directors of Public Health
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